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Food allergy in under 19s: assessment

and diagnosis
Clinical guideline
Published: 23 February 2011
nice.org.uk/guidance/cg116

NICE 2011. All rights reserved.

Food allergy in children and young people (CG116)

Contents
Introduction .......................................................................................................................................................................... 5
Patient-centred care.......................................................................................................................................................... 6
1 Guidance ............................................................................................................................................................................. 7
1.1 List of all recommendations ................................................................................................................................................. 7

2 Notes on the scope of the guidance .........................................................................................................................14


3 Implementation ...............................................................................................................................................................15
4 Research recommendations .......................................................................................................................................16
4.1 Prevalence and natural history of non-IgE-mediated food allergy....................................................................... 16
4.2 Clinical predictors of non-IgE-mediated food allergy................................................................................................ 16
4.3 Information needs for children and young people during their care pathway to diagnosis of food
allergy ................................................................................................................................................................................................... 17
4.4 Values of skin prick testing and specific IgE antibody testing and their predictive value ........................... 17
4.5 Modes of provision of support to healthcare professionals.................................................................................... 17

5 Other versions of this guideline.................................................................................................................................19


5.1 Full guideline............................................................................................................................................................................... 19
5.2 NICE Pathway ............................................................................................................................................................................ 19
5.3 Information for the public ..................................................................................................................................................... 19

6 Related NICE guidance..................................................................................................................................................20


Published ............................................................................................................................................................................................. 20

7 Updating the guideline ..................................................................................................................................................21


Appendix A: The Guideline Development Group, the Short Clinical Guidelines Technical Team,
the Short Clinical Guidelines Team and the Centre for Clinical Practice......................................................22
Guideline Development Group .................................................................................................................................................. 22
Short Clinical Guidelines Technical Team............................................................................................................................... 23
Short clinical guidelines team...................................................................................................................................................... 23
Centre for clinical practice ........................................................................................................................................................... 24

Appendix B: The Guideline Review Panel..................................................................................................................25

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Food allergy in children and young people (CG116)

About this guideline ...........................................................................................................................................................26

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Food allergy in children and young people (CG116)

This guidance has been incorporated into the food allergy in children and young people NICE
Pathway, along with other related guidance and products.

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Food allergy in children and young people (CG116)

Introduction
Food allergy is an adverse immune response to a food. It can be classified into IgE-mediated and
non-IgE-mediated reactions. Many non-IgE reactions, which are poorly defined both clinically and
scientifically, are believed to be T-cell-mediated. Some reactions involve a mixture of both IgE and
non-IgE responses and are classified as mixed IgE and non-IgE allergic reactions. Food allergy may
be confused with food intolerance, which is a non- immunological reaction that can be caused by
enzyme deficiencies, pharmacological agents and naturally occurring substances. Food intolerance
will not be covered in this guideline. The starting point for the guideline is a suspicion of food
allergy, and the use of an allergy-focused clinical history will help to determine whether a food
allergy is likely.
In its review of allergy services in 2006, the Department of Health concluded that there was
considerable variation in current practice for allergy care, with no agreed treatment pathways,
referral criteria or service models. Specifically, it was reported that many people with allergies
practised self-care, using alternative sources of support rather than NHS services (for example,
complementary services with non-validated tests and treatments).
In the NHS, most allergy care takes place in primary care. People with a clear diagnosis, and mild
but persistent symptoms, are usually managed in general practice without referral to a specialist
service. Some people with allergies, and the parents or carers of children and young people with
allergies, also buy over-the-counter medicines from community or high-street pharmacies.
However, if there is diagnostic doubt or symptoms of a more severe disease, GPs often consider
referral for a specialist opinion.

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Food allergy in children and young people (CG116)

Patient-centred care
This guideline offers best practice advice on the care of children and young people with suspected
food allergies.
Treatment and care should take into account patients' needs and preferences. Children and young
people with suspected food allergies and their families and carers should have the opportunity to
make informed decisions about their care and treatment, in partnership with their healthcare
professionals. If patients do not have the capacity to make decisions, healthcare professionals
should follow the Department of Health's advice on consent and the code of practice that
accompanies the Mental Capacity Act. In Wales, healthcare professionals should follow advice on
consent from the Welsh Government.
If the child or young person is under 16, healthcare professionals should follow the guidelines in the
Department of Health's Seeking consent: working with children.
Good communication between healthcare professionals and children and young people with
suspected food allergy is essential. It should be supported by evidence-based written information
tailored to the needs of the child or young person and their family. Treatment and care, and the
information children and young people are given about it, should be culturally appropriate. It
should also be accessible to people with additional needs such as physical, sensory or learning
disabilities, and to people who do not speak or read English.
Families and carers should also be given the information and support they need.
Care of young people in transition between paediatric and adult services should be planned and
managed according to the best practice guidance described in Transition: getting it right for young
people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to
children and young people with suspected food allergy. Diagnosis and management should be
reviewed throughout the transition process, and there should be clarity about who is the lead
clinician to ensure continuity of care.

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Food allergy in children and young people (CG116)

Guidance

The following guidance is based on the best available evidence. The full guideline gives details of
the methods and the evidence used to develop the guidance.

1.1

List of all recommendations

Assessment and allergy-focused clinical history


1.1.1

Consider the possibility of food allergy in children and young people who have
one or more of the signs and symptoms in table 1, below. Pay particular
attention to persistent symptoms that involve different organ systems.

Table 1. Signs and symptoms of possible food allergy


IgE-mediated

Non-IgE-mediated

The skin
Pruritus

Pruritus

Erythema

Erythema

Acute urticaria localised or generalised

Atopic eczema

Acute angioedema most commonly of the


lips, face and around the eyes
The gastrointestinal system
Angioedema of the lips, tongue and palate

Gastro-oesophageal reflux disease

Oral pruritus

Loose or frequent stools

Nausea

Blood and/or mucus in stools

Colicky abdominal pain

Abdominal pain

Vomiting

Infantile colic

Diarrhoea

Food refusal or aversion


Constipation
Perianal redness

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Food allergy in children and young people (CG116)

Pallor and tiredness


Faltering growth in conjunction with at least one
or more gastrointestinal symptoms above (with
or without significant atopic eczema)
The respir
respiratory
atory system (usually in combination with one or more of the abo
abovve symptoms and
signs)
Upper respiratory tract symptoms (nasal
itching, sneezing, rhinorrhoea or
congestion [with or without conjunctivitis])
Lower respiratory tract symptoms (cough, chest tightness, wheezing or shortness of breath)
Other
Signs or symptoms of anaphylaxis or other
systemic allergic reactions
Note: this list is not exhaustive. The absence of these symptoms does not exclude food allergy
1.1.2

Consider the possibility of food allergy in children and young people whose
symptoms do not respond adequately to treatment for:
atopic eczema[ ]
1

gastro-oesophageal reflux disease


chronic gastrointestinal symptoms, including chronic constipation.
1.1.3

If food allergy is suspected (by a healthcare professional or the parent, carer,


child or young person), a healthcare professional with the appropriate
competencies (either a GP or other healthcare professional) should take an
allergy-focused clinical history tailored to the presenting symptoms and age of
the child or young person. This should include:
any personal history of atopic disease (asthma, eczema or allergic rhinitis)
any individual and family history of atopic disease (such as asthma, eczema or allergic
rhinitis) or food allergy in parents or siblings
details of any foods that are avoided and the reasons why

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Food allergy in children and young people (CG116)

an assessment of presenting symptoms and other symptoms that may be associated


with food allergy (see recommendation 1.1.1), including questions about:
the age of the child or young person when symptoms first started
speed of onset of symptoms following food contact
duration of symptoms
severity of reaction
frequency of occurrence
setting of reaction (for example, at school or home)
reproducibility of symptoms on repeated exposure
what food and how much exposure to it causes a reaction
cultural and religious factors that affect the foods they eat
who has raised the concern and suspects the food allergy
what the suspected allergen is
the child or young person's feeding history, including the age at which they were
weaned and whether they were breastfed or formula-fed if the child is currently
being breastfed, consider the mother's diet
details of any previous treatment, including medication, for the presenting symptoms
and the response to this
any response to the elimination and reintroduction of foods.
1.1.4

Based on the findings of the allergy-focused clinical history, physically examine


the child or young person, paying particular attention to:
growth and physical signs of malnutrition
signs indicating allergy-related comorbidities (atopic eczema, asthma and allergic
rhinitis).

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Diagnosis
Food allergy can be classified into IgE-mediated and non-IgE-mediated allergy. IgE-mediated
reactions are acute and frequently have a rapid onset. Non-IgE-mediated reactions are generally
characterised by delayed and non-acute reactions.

IgE-mediated food allergy


1.1.5

Based on the results of the allergy-focused clinical history, if IgE-mediated


allergy is suspected, offer the child or young person a skin prick test and/or
blood tests for specific IgE antibodies to the suspected foods and likely coallergens

1.1.6

Tests should only be undertaken by healthcare professionals with the


appropriate competencies to select, perform and interpret them.

1.1.7

Skin prick tests should only be undertaken where there are facilities to deal with
an anaphylactic reaction.

1.1.8

Choose between a skin prick test and a specific IgE antibody blood test based
on:
the results of the allergy-focused clinical history and
whether the test is suitable for, safe for and acceptable to the child or young person (or
their parent or carer) and
the available competencies of the healthcare professional to undertake the test and
interpret the results.

1.1.9

Do not carry out allergy testing without first taking an allergy-focused clinical
history. Interpret the results of tests in the context of information from the
allergy-focused clinical history.

1.1.10

Do not use atopy patch testing or oral food challenges to diagnose IgE-mediated
food allergy in primary care or community settings.

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Food allergy in children and young people (CG116)

Non-IgE-mediated food allergy


1.1.11

Based on the results of the allergy-focused clinical history, if non-IgE-mediated


food allergy is suspected, trial elimination of the suspected allergen (normally
for between 26 weeks) and reintroduce after the trial. Seek advice from a
dietitian with appropriate competencies, about nutritional adequacies, timings
of elimination and reintroduction, and follow-up.

Pr
Providing
oviding information and support to the child or yyoung
oung person and their par
parent
ent or car
carer
er
1.1.12

Based on the allergy-focused clinical history, offer the child or young person and
their parent or carer, information that is age-appropriate about the:
type of allergy suspected
risk of severe allergic reaction
potential impact of the suspected allergy on other healthcare issues, including
vaccination
diagnostic process, which may include:
an elimination diet followed by a possible planned rechallenge or initial food
reintroduction procedure
skin prick tests and specific IgE antibody testing, including the safety and
limitations of these tests
referral to secondary or specialist care.

1.1.13

Offer the child or young person and their parent or carer, information that is
relevant to the type of allergy (IgE-mediated, non-IgE-mediated or mixed).

1.1.14

If a food elimination diet is advised as part of the diagnostic process (see


recommendation 1.1.11), offer the child or young person and their parent or
carer, taking into account socioeconomic status and cultural and religious issues,
information on:
what foods and drinks to avoid
how to interpret food labels

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Food allergy in children and young people (CG116)

alternative sources of nutrition to ensure adequate nutritional intake


the safety and limitations of an elimination diet
the proposed duration of the elimination diet
when, where and how an oral food challenge or food reintroduction procedure may be
undertaken
the safety and limitations of the oral food challenge or food reintroduction procedure.
1.1.15

For babies and young children with suspected allergy to cows' milk protein,
offer:
food avoidance advice to breastfeeding mothers
information on the most appropriate hypoallergenic formula or milk substitute to
mothers of formula-fed babies.
Seek advice from a dietitian with appropriate competencies.

1.1.16

Offer the child or young person, or their parent or carer, information about the
support available and details of how to contact support groups.

Referr
Referral
al to secondary or specialist car
caree
1.1.17

Based on the allergy-focused clinical history, consider referral to secondary or


specialist care in any of the following circumstances.
The child or young person has:
faltering growth in combination with one or more of the gastrointestinal
symptoms described in recommendation 1.1.1
not responded to a single-allergen elimination diet
had one or more acute systemic reactions
had one or more severe delayed reactions
confirmed IgE-mediated food allergy and concurrent asthma

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Food allergy in children and young people (CG116)

significant atopic eczema where multiple or cross-reactive food allergies are


suspected by the parent or carer.
There is:
persisting parental suspicion of food allergy (especially in children or young
people with difficult or perplexing symptoms) despite a lack of supporting
history
strong clinical suspicion of IgE-mediated food allergy but allergy test results are
negative
clinical suspicion of multiple food allergies.

Alternativ
Alternativee diagnostic tools
1.1.18

Do not use the following alternative diagnostic tests in the diagnosis of food
allergy:
vega test
applied kinesiology
hair analysis.

1.1.19

Do not use serum-specific IgG testing in the diagnosis of food allergy.

[1]

For information about treatment for atopic eczema see Atopic eczema in children (NICE clinical
guideline 57)

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Notes on the scope of the guidance

NICE guidelines are developed in accordance with a scope that defines what the guideline will and
will not cover. The scope of this guideline is available from our website click on 'How this guidance
was developed'.

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Implementation

NICE has developed tools to help organisations implement this guidance.

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Food allergy in children and young people (CG116)

Research recommendations

We have made the following recommendations for research, based on our review of evidence, to
improve NICE guidance and patient care in the future.
The focus of this guideline was the diagnosis and assessment of food allergy in children and young
people in primary care and community settings. Therefore, the management of food allergy after a
confirmed diagnosis was not reviewed. The research recommendations below focus on assessment
and diagnosis.

4.1

Prevalence and natural history of non-IgE-mediated food allergy

How common are non-IgE-mediated food allergies in children and young people in primary care
and community settings and when food allergies may be outgrown?

Wh
Whyy this is important
Food allergy has many presentations. IgE-mediated food allergy manifests itself with a relatively
homogenous group of presentations. Along with objective tests, measures of prevalence in the
relevant settings and later development of tolerance have yielded useful information on the burden
of IgE-mediated food allergy. However, non-IgE-mediated food allergy has a more heterogeneous
group of presentations and the lack of validated diagnostic tests make it very difficult to assess
prevalence without using formal diagnostic food challenges. Until high-quality prevalence studies
in primary care and community settings are carried out, the burden of this food allergy will remain
unknown. Studies should also evaluate prevalence rates and the resolution of allergies in
subgroups, such as by allergies to particular food groups, or by method of infant feeding (exclusive
formula, exclusive breastfeeding or mixed).

4.2

Clinical predictors of non-IgE-mediated food allergy

Which features in the clinical history best predict the presence of non-IgE-mediated food allergy in
children and young people in primary care and community settings?

Wh
Whyy this is important
Non-IgE-mediated food allergy often presents with non-specific problems that are common in
children and are often non-allergy related, such as colic, reflux, diarrhoea, eczema and faltering
growth. Failure to recognise food allergy causes unnecessary morbidity, whereas appropriate food
elimination can result in rapid improvement in symptoms. In the absence of a simple diagnostic test,

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it remains for the history to provide the best diagnostic clues as to which child may benefit from a
trial of an elimination diet. A validated, primary care-focused questionnaire, developed by
comparison with proven double-blind placebo-controlled food challenge outcomes, would
significantly improve the process of diagnosis.

Information needs for children and young people during their care
pathway to diagnosis of food allergy
4.3

What do children and young people with IgE-mediated food allergy and their parents or carers
want to know during the process of diagnosis and how is this demand best met?

Wh
Whyy this is important
The patient journey to diagnosis, through testing, can last for several months. The needs of children
and young people and their parents or carers, and the most effective method of information and
support provision during this time of uncertainty, need to be established.

Values of skin prick testing and specific IgE antibody testing and their
predictive value
4.4

Can skin prick testing and specific IgE antibody testing cut-off points be established to diagnose
IgE-mediated food allergy in children and young people, and to predict the severity of reaction?

Wh
Whyy this is important
It is well described that about 1 in 5 people reporting an adverse reaction to food have a true food
allergy. Of these, the majority will have non-IgE-mediated allergies. Food challenges are
cumbersome and time-consuming and there are some safety risks involved. The availability of skin
prick testing and specific IgE testing cut-off points to diagnose food allergy and to predict the
severity of reaction would therefore lead to huge cost savings in the NHS and would reduce patient
risk. There are published data available from the US, Australia and Europe, but allergists argue that
these cut-off points are population-specific and should not be used in the UK.

4.5

Modes of provision of support to healthcare professionals

What would be the impact of dietetic telephone support to healthcare professionals to aid in the
diagnosis and assessment of babies showing non-IgE-mediated food allergy symptoms in primary
care and community settings?

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Food allergy in children and young people (CG116)

Wh
Whyy this is important
There is currently no evidence to assess the impact of early diagnosis of non-IgE-mediated food
allergy on the quality of life for babies and their families. The standard method of written referral is
not timely (within the first month of presentation), yet there is no evidence whether providing
indirect dietary advice via a healthcare professional is acceptable to the family. This system,
however, could result in reduced attendances at GP surgeries and health clinics, reduced need for
unnecessary medications and treatment, improved health for the whole family and improved skills
for the healthcare professionals being supported in the diagnosis. However, it would need
increased dietetic support and skills. A community-based randomised controlled trial is needed to
compare the standard written dietetic referral method with indirect advice via a healthcare
professional following consultation with a dietitian, for families with babies aged under 1 year who
present with symptoms of non-IgE-mediated food allergy. Primary outcomes should be an
assessment of the quality of life and acceptability of this service to the family. Secondary outcome
measures could be related to attendance at GP surgeries, and medications and other interventions
implemented.

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Other vversions
ersions of this guideline

5.1

Full guideline

The full guideline, Food allergy in children and young people: Diagnosis and assessment of food
allergy in children and young people in primary care and community settings, contains details of the
methods and evidence used to develop the guideline.

5.2

NICE Pathway

This guidance has been incorporated into the food allergy in children and young people NICE
Pathway, along with other related guidance and products.

5.3

Information for the public

NICE has produced information for the public explaining this guideline.
We encourage NHS and voluntary sector organisations to use text from this information in their
own materials about diagnosis and assessment of food allergy in children and young people.

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Related NICE guidance

Published
Coeliac disease. NICE clinical guideline 86 (2009).
Diarrhoea and vomiting in children. NICE clinical guideline 84 (2009).
Atopic eczema in children. NICE clinical guideline 57 (2007).
Inhaled corticosteroids for the treatment of chronic asthma in children under the age of 12
years. NICE technology appraisal guidance 131 (2007).
Postnatal care: Routine postnatal care of women and their babies. NICE clinical guideline 37
(2006).

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Updating the guideline

NICE clinical guidelines are updated so that recommendations take into account important new
information. New evidence is checked 3 years after publication, and healthcare professionals and
patients are asked for their views; we use this information to decide whether all or part of a
guideline needs updating. If important new evidence is published at other times, we may decide to
do a more rapid update of some recommendations. Please see our website for information about
updating the guideline.

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Appendix A: The Guideline De


Devvelopment Group, the Short Clinical
Guidelines T
Technical
echnical T
Team,
eam, the Short Clinical Guidelines T
Team
eam and the
Centre for Clinical Pr
Practice
actice
Guideline Development Group
Peter Barry ((Chair)
Chair)
Consultant in Paediatric Intensive Care, University Hospitals of Leicester NHS Trust
Paula Beattie
Consultant Dermatologist, Royal Hospital for Sick Children, Glasgow
Tre
revvor Brown
Consultant Paediatric Allergist, Secondary Care, The Ulster Hospital, Northern Ireland
Sue Clark
Clarke
e
Clinical Lead/Lecturer in Allergy and Paediatric Asthma / Practice Nurse, Crown Health Centre,
Haverhill
Mandy East
Patient/Carer member, National Allergy Strategy Group & Anaphylaxis Campaign
Adam F
Fo
ox
Consultant in Paediatric Allergy, Guy's & St Thomas's Hospitals NHS Foundation Trust, London
Peter MacFarlane
Consultant Paediatrician, Rotherham General Hospital
Amanda Roberts
Patient/Carer member
Carina V
Venter
enter
Senior Dietitian, St. Mary's Hospital, Newport, Isle of Wight
Lisa W
Waddell
addell
Community paediatric dietitian, NHS Nottingham City

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Food allergy in children and young people (CG116)

Joanne W
Walsh
alsh
General Practitioner, The Medical Centre, Costessey, Norwich

Short Clinical Guidelines Technical Team


A short clinical guidelines technical team was responsible for this guideline throughout its
development. It prepared information for the Guideline Development Group, drafted the guideline
and responded to consultation comments. The following NICE employees made up the technical
team for this guideline.
Kathryn Chamberlain
Project Manager
Pr
Prashanth
ashanth Kandaswam
Kandaswamyy
Technical Adviser (Health Economics)
Hanna LLewin
ewin
Information Specialist
Alfred Sack
Sacke
eyfio
Technical Analyst
Abitha Senthinathan
Assistant Technical Analyst

Short clinical guidelines team


Mark Bak
Baker
er
Consultant Clinical Adviser
Nicole Elliott
Associate Director
Beth Sha
Shaw
w
Technical Adviser

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Centre for clinical practice


Emma Banks
Guidelines Coordinator
Stefanie Rek
Reken
en
Technical Analyst (Health Economics)
Judith Richardson
Associate Director
Nicole T
Task
aske
e
Technical Adviser
Claire T
Turner
urner
Guidelines Commissioning Manager

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Food allergy in children and young people (CG116)

Appendix B: The Guideline Re


Review
view P
Panel
anel
The Guideline Review Panel is an independent panel that oversees the development of the
guideline and takes responsibility for monitoring The Guideline Review Panel is an independent
panel that oversees the development of the guideline and takes responsibility for monitoring
adherence to NICE guideline development processes. In particular, the panel ensures that
stakeholder comments have been adequately considered and responded to. The panel includes
members from the following perspectives: primary care, secondary care, lay, public health and
industry.
John Hyslop ((Chair)
Chair)
Consultant Radiologist, Royal Cornwall Hospital NHS Trust
Sar
Sarah
ah Fishburn
Lay member
Kier
Kieran
an Murph
Murphyy
Health Economics & Reimbursement Manager, Johnson & Johnson Medical Devices & Diagnostics
(UK)
Ash P
Paul
aul
Deputy Medical Director, Health Commission Wales
Liam Smeeth
Professor of Clinical Epidemiology, London School of Hygiene and Tropical Medicine

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About this guideline


NICE clinical guidelines are recommendations about the treatment and care of people with specific
diseases and conditions in the NHS in England and Wales.
The guideline was developed by the Short Clinical Guidelines Technical Team. The team worked
with a group of healthcare professionals (including consultants, GPs and nurses), patients and
carers, and technical staff, who reviewed the evidence and drafted the recommendations. The
recommendations were finalised after public consultation.
The methods and processes for developing NICE clinical guidelines are described in The guidelines
manual. This guideline was developed using the short clinical guideline process.
The recommendations from this guideline have been incorporated into a NICE Pathway. We have
produced information for the public explaining this guideline. Tools to help you put the guideline
into practice and information about the evidence it is based on are also available.
Changes after publication
December 2011: minor maintenance
March 2013: minor maintenance
Your responsibility
This guidance represents the view of NICE, which was arrived at after careful consideration of the
evidence available. Healthcare professionals are expected to take it fully into account when
exercising their clinical judgement. However, the guidance does not override the individual
responsibility of healthcare professionals to make decisions appropriate to the circumstances of
the individual patient, in consultation with the patient and/or guardian or carer, and informed by
the summary of product characteristics of any drugs they are considering.
Implementation of this guidance is the responsibility of local commissioners and/or providers.
Commissioners and providers are reminded that it is their responsibility to implement the
guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have
regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a
way that would be inconsistent with compliance with those duties.

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Food allergy in children and young people (CG116)

Cop
Copyright
yright
National Institute for Health and Clinical Excellence 2011. All rights reserved. NICE copyright
material can be downloaded for private research and study, and may be reproduced for educational
and not-for-profit purposes. No reproduction by or for commercial organisations, or for
commercial purposes, is allowed without the written permission of NICE.
Contact NICE
National Institute for Health and Clinical Excellence
Level 1A, City Tower, Piccadilly Plaza, Manchester M1 4BT
www.nice.org.uk
nice@nice.org.uk
0845 033 7780

Accreditation

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